Silver Plan 100%-150% FPL. Member Cost Share. Member Cost Share. Member Cost Share. Deductible Applies. Deductible Applies. Deductible Applies

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1 A California Health Benefit Exchange QHP Certification Application for Plan ear 2018 Attachment B Standard Benefit Plan Design Deviation Indicate requests for deviations from the 2018 Standard Benefit Plan Designs be entering alternate cost sharing for the appropriate service type. Applicant must document rationale for each requested deviation, and rationale must include reference to regulatory compliance, administrative or operational barriers to implementing the 2018 Standard Benefit Plan Designs. V C a Platinum Coinsurance Plan Platinum Copay Plan Gold Coinsurance Plan Gold Copay Plan Silver Plan Bronze Plan Silver Plan 100%150% FPL Silver Plan 150%200% FPL Silver Plan 200%250% FPL Bronze Plan Bronze HDHP Plan Catastrophic Plan Rationale for benefit deviation (must reference regulatory compliance, administrative or operational barriers) Common Medical Event Service Type Cost Cost Cost Cost Cost Cost Cost Cost Cost Cost Cost Cost Primary care visit to treat an injury, illness, or condition Routine Foot Care Health care Other practitioner office visit provider s office Acupuncture or clinic visit Diabetes Education Specialist visit Allergy Testing Preventive care/ screening/ immunization Tests Drugs to treat illness or condition Laboratory Tests Xrays and Diagnostic Imaging Imaging (CT/PET scans, MRIs) Tier 1 Tier 2 Tier 3 Tier 4 Surgery facility fee (e.g., C Abortion for Which Public Funding is Prohibited (non MSP) Outpatient services Bariatric Surgery Physician/surgeon fees Outpatient visit Dialysis C o Radiation Chemotherapy Infusion Therapy Emergency room combined facility and physician fee (waived if admitted) Emergency medical transportation Need immediate attention Urgent care Facility fee (e.g. hospital room) Hospital stay Transplant Reconstructive Surgery Treatment for TMJ Physician/surgeon fee Mental/Behavioral health outpatient office visits Mental/Behavioral health other outpatient items and services Mental health, Mental/Behavioral health inpatient facility fee (e.g. hospital behavioral room) health, or Mental/Behavioral health inpatient physician/surgeon fee substance abuse needs Substance Use disorder outpatient office visits Substance Use disorder other outpatient items and services Substance Use inpatient facility fee (e.g. hospital room) Substance use disorder inpatient physician/surgeon fee Prenatal care and preconception visits Pregnancy Delivery and all inpatient services Hospital Professional Well Baby Visits Home health care Outpatient Rehabilitation services Rehabilitative Speech Therapy Rehabilitative Occupational Therapy Help recovering or other special Rehabilitative Physical Therapy health needs Outpatient Habilitation services Skilled nursing care Durable medical equipment Prosthetic Device Hospice service Eye exam Child eye care 1 pair of glasses per year (or contact lenses in lieu of glasses) Oral Exam Preventive Cleaning Child Dental Preventive Xray Diagnostic and Sealants per Tooth Preventive Topical Fluoride Application Space Maintainers Fixed Child Dental Amalgam Fill 1 Surface Basic Services Root Canal Molar Gingivectomy per Quad Child Dental Extraction Single Tooth Exposed Root or Erupted Major Services Extraction Complete Bony Porcelain with Metal Crown Child Medically necessary orthodontics Orthodontics Additional Benefits Adult Eye Exam Chiropractic

2 QHP Certification Application for Plan ear 2018 Attachment C1 Current & Projected Enrollment Please provide the following for each product (HMO/PPO/EPO/HSP) in the small group market: 1 Effectuated Enrollment as of April 1, Applicants not currently contracted should leave 2017 effectuated columns blank Enrollment Projections. These should reflect anticipated enrollment for the Plan ear Data submitted must be consistent with all SERFF templates and any other application submissions. Rating Region County 2017 Effectuated Alpine Del Norte Siskiyou Modoc Lassen Shasta Trinity Humboldt Tehama Plumas Nevada Sierra Mendocino Lake Butte Glenn Sutter uba Colusa Amador Calaveras Tuolumne Region 2 Napa Region 2 Sonoma Region 2 Solano Region 2 Marin Region 3 Sacramento Region 3 Placer Region 3 El Dorado Region 3 olo Region 4 San Francisco Region 5 Contra Costa Region 6 Alameda Region 7 Santa Clara Region 8 San Mateo Region 9 Santa Cruz Region 9 Monterey Region 9 San Benito 0 San Joaquin 0 Stanislaus 0 Merced 0 Mariposa 0 Tulare 1 Fresno 1 Kings 1 Madera 2 San Luis Obispo 2 Ventura 2 Santa Barbara 3 Mono 3 Inyo 3 Imperial 4 Kern 5 Los Angeles 6 Los Angeles 7 San Bernardino 7 Riverside 8 Orange 9 San Diego Statewide Total HMO PPO EPO HSP 2018 Enrollment 2017 Effectuated 2018 Enrollment 2017 Effectuated 2018 Enrollment 2017 Effectuated 2018 Enrollment

3 QHP Certification Application for Plan ear 2018 Attachment C2 California Off Exchange Enrollment Please provide current enrollment as of April 1, 2017 for each line of business. ship for employer based coverage should be reported based on member residence address as opposed to employer location. Data submitted must be consistent with all SERFF templates and any other application submissions. Rating Region County EmployerBased Individual Market Government Payers Region 2 Region 2 Region 2 Region 2 Region 3 Region 3 Region 3 Region 3 Region 4 Region 5 Region 6 Region 7 Alpine Del Norte Siskiyou Modoc Lassen Shasta Trinity Humboldt Tehama Plumas Nevada Sierra Mendocino Lake Butte Glenn Sutter uba Colusa Amador Calaveras Tuolumne Napa Sonoma Solano Marin Sacramento Placer El Dorado olo San Francisco Contra Costa Alameda Santa Clara CalPERS Large Group Small Group Mirrored Off Exchange NonMirrored Off Exchange Tricare MediCal Medicare

4 Region 8 Region 9 Region 9 Region San Mateo Santa Cruz Monterey San Benito San Joaquin Stanislaus Merced Mariposa Tulare Fresno Kings Madera San Luis Obispo Ventura Santa Barbara Mono Inyo Imperial Kern Los Angeles Los Angeles San Bernardino Riverside Orange San Diego Statewide Total

5 QHP Certification Application for Plan ear 2018 Attachment D2 Annual Marketing Plan APPLICANT NAME Annual Marketing Plan Marketing Activities July 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar 2018 Apr 2018 May 2018 June 2018 TOTAL MARKETING BUDGET AGENT COMMUNICATIONS Agent briefings/webinars Newsletters Point of Sale Collateral to support agents EMPLOER MARKETING Print Advertising (Newsprint, Magazine, Trade publications) Radio Advertising Search Engine Marketing Digital Advertising (display, video, mobile) Social media marketing Direct mail Lead purchasing Other advertising/promotional activities OTHER Community Events Note: Include only marketing activities/budget pertaining to Small Business. Highlight the months when marketing activities are planned.

6 QHP Certification Application for Plan ear 2018 Attachment D3 Estimated Annual Marketing Budget by Geography APPLICANT NAME Estimated Annual Marketing Budget B GEOGRAPH Marketing Activities Los Angeles/Orange County San Francisco Oakland San Jose Sacramento Stockton Modesto San Diego FresnoVisalia Inland Empire Other Areas TOTAL AGENT COMMUNICATIONS Agent briefings/webinars Newsletters Point of Sale Collateral to support agents EMPLOER MARKETING Print Advertising (Newsprint, Magazine, Trade publications) Radio Advertising Search Engine Marketing Digital Advertising (display, video, mobile) Social media marketing Direct mail Lead purchasing Other advertising/promotional activities OTHER Community Events TOTAL Note: Include only marketing activities/budget pertaining to Small Business.

7 QHP Certification Application for Plan ear 2018 Attachment G Alternate Benefit Design Enter costsharing amounts as copays or coinsurance that describe the enrollee's outofpocket costs for each benefit category, including applicability of deductible. List any exclusions in the column on the right. Columns left blank will be interpreted as not offered. Bronze Alternate Plan/ Bronze HDHP Alternate Bronze Alternate Plan 2/ Bronze HDHP Alternate Plan 2 Silver Alternate Plan/ Silver HDHP Alternate Plan Silver Alternate Plan 2/ Silver Alternate HDHP Plan 2 Gold Alternate Plan Gold Alternate Plan 2 Platinum Alternate Plan Platinum Alternate Plan 2 Plan Type (HMO, EPO, PPO, etc.) Non Non Non Non Non Non Non Non Estimated Actuarial Value % % % % % % % % % % % % % % % % Overall deductible Other deductibles for specific services Facilityrelated Services Brand Drugs Dental Out of pocket limit on expenses Service Type Health care provider's office or clinic visit Primary care visit to treat an injury, illness, or condition Routine Foot Care Other practitioner office visit Acupunture Specialist visit Allergy Testing Preventive care/ screening/ immunization Tests Laboratory Tests Xrays and Diagnostic Imaging Imaging (CT/PET scans, MRIs) Drugs to treat illness or condition Tier 1 Tier 2 Tier 3 Tier 4 Outpatient services Surgery facility fee (e.g., ASC) Abortion (non MSP) Bariatric Surgery Physician/surgeon fees Outpatient visit Dialysis Radiation Infusion Therapy Chemotherapy Need immediate attention Emergency room combined facility and physicians fee (waived if admitted) Emergency medical transportation Urgent care Hospital stay Facility fee (e.g., hospital room) Organ Transplant

8 Bronze Alternate Plan/ Bronze HDHP Alternate Bronze Alternate Plan 2/ Bronze HDHP Alternate Plan 2 Silver Alternate Plan/ Silver HDHP Alternate Plan Silver Alternate Plan 2/ Silver Alternate HDHP Plan 2 Gold Alternate Plan Gold Alternate Plan 2 Platinum Alternate Plan Platinum Alternate Plan 2 Plan Type (HMO, EPO, PPO, etc.) Reconstructive Surgery Treatment for TMJ Physician/surgeon fee Mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient office visit Non Non Non Non Non Non Non Non Mental/Behavioral health other outpatient items and services Mental/Behavioral health inpatient facility fee (e.g. hospital room) Mental/Behavioral health inpatient physician/surgeon fee Substance Use disorder outpatient office visits Substance Use disorder other outpatient items and services Substance Use inpatient facility fee (e.g. hospital room) Substance use disorder inpatient physician/surgeon fee Pregnancy Prenatal care and preconception visits Delivery and all inpatient services Hospital Delivery and all inpatient services Professional Help recovering or other special health needs Home health care Outpatient Rehabilitation services Rehabilitative Speech Therapy Rehabilitative Occupational Therapy Rehabilitative Physical Therapy Outpatient Habilitation services Skilled nursing care Durable medical equipment Prosthetic Device Hospice service Child eye care Eye exam 1 pair of glasses per year (or contact lenses in lieu of glasses) Child Dental Diagnostic and Preventative Oral Exam Preventive Cleaning Preventive Xray Sealants per Tooth Topical Fluoride Application Space Maintainers Fixed Child Dental Basic Services Amalgam Fill 1 Surface Child Dental Major Services

9 Bronze Alternate Plan/ Bronze HDHP Alternate Bronze Alternate Plan 2/ Bronze HDHP Alternate Plan 2 Silver Alternate Plan/ Silver HDHP Alternate Plan Silver Alternate Plan 2/ Silver Alternate HDHP Plan 2 Gold Alternate Plan Gold Alternate Plan 2 Platinum Alternate Plan Platinum Alternate Plan 2 Plan Type (HMO, EPO, PPO, etc.) Root Canal Molar Gingivectomy per Quad Extraction Single Tooth Exposed Root or Erupted Extraction Complete Bony Porcelain with Metal Crown Child Orthodontics Non Non Non Non Non Non Non Non Medically necessary orthodontics Additional Benefits Chiropractic Infertility Adult Eye Exam